Compliance Program Elements

The Seven Fundamental Compliance Program Elements

Written Policies and Procedures

Standards of Conduct

The Alegent Creighton Health Standards of Conduct Policy and Procedure (300.004) is Alegent Creighton Health’s guide for ethical and professional business conduct. It is each individual’s responsibility to adhere to the Standards of Conduct and to actively participate in and promote compliance and integrity.

Risk Areas

The Alegent Creighton Health Corporate Integrity Program Document and Standards of Conduct address but a few of the rules and regulations that a healthcare provider must adhere to on a daily basis. Alegent Creighton Health identifies areas where the organization may be at risk for noncompliance and addresses and corrects these areas.

Alegent Creighton Health’s CEO and General Counsel, an internal audit representative, and other representatives from senior leadership, appointed by the CEO, all serve on the Alegent Creighton Health Corporate Integrity Committee.

Conducting Effective Training and Education

Since 1999, Corporate Integrity annual education has been provided to all employees on a wide variety of topics. Such topics as fraud and abuse, gifts and gratuities, Stark and Anti-kickback statutes, HIPAA, Limited English Proficiency and much more have been presented. In addition to the annual education requirement, specialty training is prepared and presented to appropriate staff as the need arises.

In addition to the one hour of required employee training, managers receive an additional hour of specialized training.

Developing Effective Lines of Communication

The Compliance Officer is available through many communication methods – phone, in-person, fax, e-mail, pager and Corporate Integrity Hotline.

Enforcing Standards Through Well-Established Disciplinary Guidelines

Not reporting an issue of suspected non-compliance could have serious consequences. Suspected issues of noncompliance should be reported to a manager or the Compliance Officer. Alegent Creighton Health does not allow any retaliation against an individual who reports an issue that the individual suspects is wrong. An individual cannot be terminated when the individual, in good faith, reports an issue they thought was non-compliant.

Auditing and Monitoring

The payor billing rules are complicated and rapidly changing. Many times we really believe that we are doing something correctly but may, in fact, not be. Have we committed an act of fraud? Probably not, because we did not intentionally bill something incorrectly.

That is why we audit and monitor and audit and monitor. To make sure we are doing things correctly, to fix the situation if not correct, and to make sure that is stays corrected.

If during an audit, internal or external, an issue is identified and no action is taken to correct the issue and we continue to do the incorrect thing, this may be considered fraud. The Office of Inspector General (OIG) favorably looks upon internal action, correction and reporting.

However, there is nothing worse than developing a corrective action plan, believing that we are correcting an issue, but then not actually correcting it. Payor representatives retain copies of our corrective action plans and use them during other medical reviews. If we say we are going to correct something, we need to do it and then make sure the corrections stay in place.

That is why Alegent Creighton Health has a Corporate Integrity Program. We are committed to act with integrity in everything we do and providing our patients with quality care. Our Corporate Integrity Program gives us an additional tool to meet and exceed our commitment to our patients.